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Clinical Review

Management of the severely malnourished child: perspective from developing countries

BMJ 2003; 326 doi: (Published 18 January 2003) Cite this as: BMJ 2003;326:146

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How to identify the malnourished child.

The article by Bahn et al. is an excellent contribution to the debate
on how to approach the treatment of malnutrition in children.
Treatment of malnutrition however, can only start after identification of
the child suffering from it. Although this sounds straightforward, it is
not an easy task.

The authors promote to use the WHO criteria for diagnosing
malnutrition, which include calculating Z-scores for weight-for-height
(WHZ) and height-for-age (HAZ).

Rural hospitals in resource poor areas are often severely
understaffed, but at the same time have a high admission rate of
especially small children. It should not be underestimated how much
strain, measuring height of all admitted children puts on the
medical/nursing staff. It is considered to be too time consuming and of
little value in establishing the diagnosis, and is therefore, not
surprisingly, often left out in the assessment of the child.

During my years of work in rural Kenya, I noticed that in many
hospitals the diagnosis of malnutrition is only made on clinical grounds
like weight, presence of pedal oedema or discolouration of the hair.

In an attempt to quantify the correlation between clinical diagnosis
and more objective assessment through anthropometric indices, we conducted
a study in one of the rural hospitals in Western Kenya (Misikhu Mission
Hospital).(1) For a period of 5 months, all admitted children under the
age of 5 years (n=1130), had their anthropometric indices calculated (WHZ
and HAZ) using Epi-Info software, and then compared with the clinical

Sixteen percent of the admitted children was wasted (WHZ < 2
standard deviation (SD) below the mean), and an addittional 16% was
stunted (HAZ < 2SD below the mean). Just 14% of the wasted children
and 11% of the stunted children were identified by clinical assessment as
having malnutrition, and would have got appropriate treatment when only
clinical parameters were taken into account at the time of diagnosis.

It is therefore without any doubt that measuring height can not be
left out when assessing the possible presence of malnutrition in a child.
Once the diagnosis is made, the guidelines mentioned by Bahn et al. should
help the treating physician in the actual treatment of the malnourished

1: F.C.M. van Leth, J.M. Koeleman, A.S. Manya. Malnutrition: More
than the eye can see. East Afr Med J.2000;77 (10):549-51

Competing interests:  
None declared

Competing interests: No competing interests

26 January 2003
Frank van Leth
Clinical Epidemiologist
International Antiviral Therapy Evaluation Center. Meibergdreef 9, 1105 AZ Amsterdam, The Netherland